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Deactivation of Implantable Cardioverter Defibrillator Extravasation of IV Amiodarone Anticoagulation for AF, DVT and PE Patients Returning from Interventional Cardiac Procedure Cardiology Referrals STEMI Thrombolysis Protocol STEMI Hypertensive Emergencies Rate Control in AF Heart Failure Aortic Dissection Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Pericardiocentesis Pacemakers Indications for Echocardiography Bradycardia Narrow Complex Tachycardia Anti-Platelet Therapy in Coronary Heart Disease Management of Acute AF Rhythm Control in AF Atrial Fibrillation Hypertension Ventricular Tachycardia Cardiogenic Shock Complicating Acute Coronary Syndrome Telemetry
Home | Articles | Cardiac | Hypertensive Emergencies

Hypertensive Emergencies

Last updated 22nd March 2024

Calls concerning HT are frequent at night but rarely require the use of drugs that rapidly reduce pressure.

Hypertensive Emergencies

  1. Consider HT heart failure, HT encephalopathy, aortic dissection, eclampsia and phaeochromocytoma crisis.
  2. Best IV drugs are nitrate for heart failure, labetolol for encephalopathy and aortic dissection, phentolamine for phaeo crisis, magnesium sulphate to control fits in eclampsia, but in each case you should discuss with senior medical staff first.
  3. The use of sublingual nifedipine has been abandoned as it may cause a precipitous fall in pressure.
  4. For advice on management of hypertension in acute haemorrhagic stroke and ischaemic stroke – Click Here for Management of Hypertension in Acute Stroke

Hypertensive Urgencies

  1. The commonest of these is uncomplicated malignant HT (DBP usually >130mmHg with bilateral retinal haemorrhages and exudates and/or papilloedema)
  2. Usual initial treatment is oral bisoprolol 2.5-5mg daily or oral amlodipine 5-10mg daily in patients not already taking anti-HT drugs.

Severe Asymptomatic Hypertension

  1. Much more common than HT emergency or HT urgency.
  2. In patients who are not already taking antihypertensive drug therapy consider bisoprolol 2.5-5mg or amlodipine 5-10mg if SBP >180mmHg and/or DBP >110mmHg with repeated measurement.
  3. In all other instances ask for repeated measurements but leave till morning.

Check List for BP>180/110

  1. Most patients will be asymptomatic.
  2. Check compliance if already on treatment
  3. Examine CVS to exclude heart failure.
  4. Examine fundi to exclude haemorrhages, exudates and papilloedema (if in doubt dilate).
  5. Examine CNS to exclude encephalopathy and stroke.
  6. Clue to phaeo crisis is paroxysm of hypertension with headache, sweating, palpitation and pallor – rare.
  7. Clues to aortic dissection are tearing chest pain which radiates to back, pallor (shocked yet hypertensive), loss of pulses, aortic diastolic murmer – rare
  8. Palpate for bladder dullness – urinary retention in male with prostatic disease can raise blood pressure.
  9. Check U&E if not already known.
  10. Consider whether treatment appropriate as above.

How to Use IV Labetalol

  1. To reconstitute, dilute 200mg in 200ml 5% dextrose to give concentration 1mg/ml
  2. Infuse at 2mg/min until satisfactory response achieved. This will usually be by time 2mg/kg has been given.
  3. Then either stop infusion or continue at a lower rate to maintain desired level of pressure.
  4. Alternatively give 20mg IV bolus every 10 min to a maximum of 300mg if required
  5. Onset of action for Labetalol is 5-15 min, duration 4-6 hours.
  6. Avoid in systolic heart failure, second or third degree AV block, asthma and in phaeochromocytoma (insufficient alpha blockade)

How to Use IV Nitrate

  1. Prepare the infusion by drawing up a 50ml syringe of ready mixed glyceryl trinitrate (50mg in 50ml)
  2. Start infusion at 1mg/hour
  3. Dose range is 1-10mg/hour to achieve and maintain desired level of pressure.
  4. Onset of action for IV nitrate is 3-5 min, duration 3-5 min.
  5. Avoid if volume deplete
  6. Tolerance can limit usefulness
  7. As with all infusion solutions, any unused portion should be discarded after 24 hours

Updated by Chris Isles